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Saturday, October 2, 2010

Serious Case Reviews in the UK

The UK has just seen the publication of an overview of Serious Case Reviews for the period 2007-2009. Maybe only us academics will find it of interest but they have brought an important new dimension to their review - consideration of children who die or are seriously harmed in the community as opposed to within the family system. This is a perspective not often considered.

Before looking at this new dimension, there is reinforcement of the role that various community practitioners play in protecting the lives of the vulnerable - particularly the very young. As is often seen, the most vulnerable children are those under the age of 5 - the age where it is hardest for the child to have a meaningful voice about what is going on in the family. Thus, general practitioners, community nurses and other professionals that come into contact with these families are typically the most informed set of eyes about the family. If they do not stay alert to what concerns may be there for a child, it is unlikely that the problems are going to be addressed.

The report offers a good practice lesson when working with larger families. "Our analysis of a sub-set of these cases indicated that neglect featured prominently and
highlighted the danger that when agencies work with large families the focus on
an individual child can easily be lost" (p.27). More complex family dynamics can hinder the view of each child's needs. As Pearce and Pezzot-Pearce note in their book on parenting assessments in child protection matters, one is considering the ability to each parent in respect of each child. If the individual needs of a child is lost in a crowd, then it is not difficult to see the report author's concern.

Stanley et al., (2010, in press) remind us that domestic violence is a prevalent concern in high risk families. They state, "...domestic violence had been identified as a key feature in local reviews of child deaths and this is consistent with Brandon et al.’s (2009) overview of 40 serious case reviews in England which found that domestic violence was the most commonly occurring characteristic in the child deaths studied." What goes on in the home can help to normalize risk, violence, trauma and harm. This can make the connections to such behaviors and environments in the community that much easier and perhaps normal and expected.

In looking at the issues of harm in the community, it is also important to recognize the following point: Taking into account the children‟s ages, it is not surprising that the younger the child, the more likely it is that the abuse or maltreatment will occur at home. Older young people, who become, increasingly, part of the wider community as they age, are more likely to be harmed or to self-harm within a community context. As young people mature, outside family factors and „triggers‟ take on more importance in their lives and the perpetrators
of harm are less likely to be family members. However, young people still carry with
them the legacy of their early experiences of care and nurture which influences their ability to either cope with or to struggle to withstand outside influences" (p.29).

In terms of risk to children from the community, the report raises a fascinating point: Excluding young people from school has a wide ranging impact and limits their
protection and their access to a range of other services". (p.31). Suspending or expelling children from school invites them to become connected to other peers who are in a similar setting. A discussion needs to begin across a broad base of educators, social workers and other professionals to develop alternatives to avoid pushing children toward anti-social groupings. Are there ways to have children in school somehow contributing to the school in response to anti-social transgressions.

With children involved with child protection, the older they are the more able they are to be involved in high risk behaviors - sex, drugs and rock and roll to use an old metaphor. Regrettably, much research tells us that the older child is much more likely to be involved in these patterns if they have not had effective interventions when they are younger - this might be because of problems being unaddressed or cases dragging on with poor or ineffective case planning allowing the child to experience prolonged uncertainty about their lives.

When the authors looked at the older child who came to serious harm or death in the community, the authors notes, "Most young people had experienced neglect and or abuse and had grown up living with the „toxic trio‟ of family violence, parental substance misuse and parental mental ill health" (p.33). Combine this with poverty, housing instability, relationship changes and you can see the cumulative impact on families - stress levels grow over time with little chance for relief. Children become just another one of the sressors. This really emphasizes the need to think of families in an ecological perspective.

An important point is made about younger children harmed in the community. "Risks of harm to children „in the community‟ were posed within formal, regular child care arrangements (for example from a nanny and from un-registered child-minders and from a sexual offender whose wife was a registered childminder). Harm within the context of more informal, ad hoc childcare of young pre-school aged children came from leaving children in the care of unsuitable and often unstable young people or adults. Usually these informal carers or babysitters were known or loosely connected to the family, for example the teen-aged son of a mother‟s boyfriend" (p. 35). Far too often, marginalized families are forced to rely on whatever child minding might be available. These families often have very few choices for child care yet need the support in order to try and make ends meet.

The review also raises a very salient point about risk. We are more prone to worry about those with a history of known inappropriate behaviors but there are those for whom people have a concern, even though it is not substantiated. The authors state, "A number of sexual assaults were not from known sex offenders but from other
individuals about whom there were serious concerns, for example “a known associate of the family about whom many long standing concerns had been held" (p.38). When we use multiple sources of information about what is going on in a family, we may better identify those who constitute a risk for children including such as these individuals. From a practice level, this allows us to see a family from the more complex level of not only who is in the family but also who is informally involved with and perhaps trying to support the family and may be not appropriately so.

As the authors note, there are also recurring themes that are good clinical practice lessons. There are some children who are just very difficult and can stress a families ability to cope. As the report notes, "There are recurring themes about the particular vulnerability of many of the babies at the centre of the reviews, especially prematurity, time spent in intensive neo-natal care, drug
addicted babies, and „difficult‟ babies. All these factors present particular stresses for caregivers, and potentially dangers for the baby, especially where the family is already struggling and experiencing other difficulties" (p.52). Combine a parent with weak parental capacity and a demanding baby and you have a toxic mix.

We can make the mistake of assuming, however, that as children grow and become attached to schools that risks may diminish. The child is away from home more and there is more oversight. This may be a false assumption and care should be taken to not fall into it. It may well be that the risk of death diminishes but not the risk of injury.

As has been seen in other places, these authors also warn us about "Start again syndrome" where practitioners see a new baby or a new partner or a new something as a way for a family or a parent to start over and let go of past patterns. Indeed, with this thinking, the past patterns are often poorly understood or even ignored. The report raises other lessons that we have seen before:

* parents who are non-cooperative, miss appointments, fail to follow through or somehow manage to fall off the radar are then not achieving real change;
* social workers overwhelmed with high caseloads missing details or just not able to follow up on crucial data;
* the need for strong relationship building to be effective with families;
* being wary of the rule of optimism in which workers want to feel successful and are therefore reluctant to be negative or critical of families;
* being unwilling to change your mind about a case - once a view is adopted sticking with it despite new evidence that should alter the view;
* failing to see or interview all of the children creating the missing or unseen child.

Stanley et al., (2010, in press) reminds us that involving professionals from various agencies with varying roles brings more eyes into troubled families. Of course, there must be ways for the agencies to communicate or they operate in a vacuum which allows higher risk families to manipulate who knows what.


Brandon, M., Bailey, S., Belderson P. (2010).Building on the learning from serious case reviews:A two year analysis of child protection database notifications 2007-2009. East Anglia, University of East Anglia.

Stanley, N., Miller, P.Foster, H.R., Thomson, G.(2010). Children’s Experiences of Domestic Violence:Developing an Integrated Response From Police and Child Protection Services. Journal of Interpersonal Violence, In Press.

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